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CHICAGO – Launched several decades ago as an anesthetic for animals and humans, it has become a powerful painkiller on the battlefield in Vietnam and has evolved to become the drug of the trippling club, Special K.
The chameleon drug, ketamine, is finding new life as an unapproved treatment for depression and suicidal behavior. In the United States, clinics have opened and promise immediate relief with their "single" doses of ketamine in intravenous infusions, aerosols or pills. And desperate patients spend thousands of dollars for treatment often not covered by health insurance, with little evidence on the benefits and long-term risks.
Chicago preschool teacher Lauren Pestikas has long battled depression and anxiety and made several suicide attempts before trying ketamine earlier this year.
The price to date is about $ 3,000, but "it's worth every penny and every penny," said the 36-year-old.
Pestikas said that she felt much better for a few weeks after each treatment, but the effects fade and she struggles to find a way to pay for another.
For now, the US Food and Drug Administration has not approved ketamine for treating depression, although doctors can use it for this purpose.
Ketamine has been around since the 1960s and is widely used as an anesthetic drug during surgery because it does not suppress breathing. Compared with opioids such as morphine, ketamine is not addictive and does not cause breathing problems. And some studies have shown that ketamine can relieve symptoms within hours in the most severe cases.
Its potential effects on depression have been discovered in animal experiments conducted in the late 1980s and early 1990s, showing that glutamate, a chemical messenger of the brain, may play a role in depression. and that drugs, including ketamine, that target the glutamate pathway, may act as antidepressants.
Conventional antidepressants, such as Prozac, target serotonin, a different chemical messenger, and usually take weeks or months to get into action – a shift that can cause severely depressed patients to fall into despair.
The potential of ketamine for almost immediate relief if temporary is what makes it so exciting, said Dr. Jennifer Vande Voort, a psychiatrist at the Mayo Clinic who treats patients with depression since February.
"We do not have many things that produce this kind of effect. My concern is that the situation is so excited, "she said.
The strongest studies suggest that it is the most useful and generally safe to provide short-term help to patients who have not benefited from antidepressants. That's about one-third of the world's estimated 300 million people with depression.
"This has really revolutionized the field," has changed scientists' view of the effects of depression on the brain and shows that rapid relief is possible, said the Yale University psychiatrist. Gerard Sanacora, who has researched or consulted companies seeking to develop ketamine. based drugs.
But to become a standard treatment for depression, he said, there is still much to be done.
Last year, Sanacora co-authored a report of the American Psychiatric Association's Task Force on Ketamine Treatment for Mood Disorders, highlighting the benefits, but stating that "significant shortcomings Remain in knowledge about long-term efficiency and safety. Most studies have been modest, conducted in research contexts and not in the real world.
When administered intravenously, ketamine can cause a rapid increase in heart rate and blood pressure, which can be dangerous for some patients. Ketamine can also cause hallucinations that some patients find scary.
"There are very real concerns," said Sanacora. "We know that this medicine can be misused, so we need to be very careful about how it is developed."
Dr. Rahul Khare, a specialist in emergency medicine in Chicago, discovered for the first time, a decade ago, the other potential benefits of ketamine by a depressed and anxious patient that it was safe to use. was preparing to calm down to repair a dislocated shoulder several times.
"He said, 'Doc, give me what I had last time. I felt so much better for about three weeks, "recalls Khare.
Khare became intrigued and earlier this year he began to offer ketamine for the treatment of severe depression at an outpatient clinic that he opened a few years ago. He also joined the American Society for Ketamine Physicians, created a year ago, representing about 140 doctors, nurses, psychologists and other Americans, using ketamine for depression or other unapproved uses.
There are about 150 ketamine treatment clinics in the United States, up from about 20 three years ago, said company co-founder Dr. Megan Oxley.
Khare said that the burgeoning field "is like a new frontier" where doctors meet at meetings and compare notes. He treated about 50 patients with depression, including Pestikas. They are usually desperate for relief after failing to respond to other antidepressants. Some have lost their jobs and relationships because of severe depression, and most find that ketamine allows them to function, Khare said.
The typical treatment at his clinic includes six 45-minute sessions over approximately two weeks, at a cost of $ 550 each. Some insurers will pay about half of it, covering the cost of visiting Khare's office. Patients may receive "booster" treatments. They must sign a four-page consent form stating that the benefits may not be sustainable, listing potential side effects and in bold, the treatment is not approved by the government.
In a recent session, the seventh of Pestikas, she leaned against a reclining white chair while a nurse connected her to a heart monitor and her blood pressure monitor. She grimaced when a needle slipped into the palm of her left hand. Khare raised her hand with a syringe to inject a small dose of ketamine into an infusion bag hanging over the chair, then lowered the light, pulled the curtains out of the window and asked if she had any questions and if she felt well.
"No questions, just grateful," Pestikas replied with a smile.
Pestikas listened to music on his iPhone and watched psychedelic videos. She said it was like "a controlled acid trip" with pleasant hallucinations. The trip ends shortly after the withdrawal of the infusion, but Pestikas said that she felt calm and relaxed the rest of the day and that the mood rush could last for weeks.
Studies suggest that a single intravenous dose of ketamine much smaller than that used for sedation or feasting can help many patients get relief in about four hours and for nearly a week.
The exact functioning of ketamine is not clear, but one idea is that, by increasing glutamate levels, ketamine helps nerve cells restore connections that were invalidated by depression, said Dr. Carlos Zarate , expert in ketamine, head of experimental therapies at the National Institute of Mental Health. .
A small Stanford University study published in August suggested that ketamine can help relieve depression by activating opioid receptors in the brain.
Janssen Pharmaceuticals and Allergan are among the pharmaceutical companies developing ketamine-like drugs for depression. Janssen is leading the effort with his esketamine nasal spray. The company filed a new drug application in September.
At the same time, dozens of studies are under way to try to answer some of the unknowns of ketamine, including whether repeated IV treatments are more effective against depression and whether it is possible to target patients who will benefit the most.
Until there are answers, Zarate from the Mental Health Institute said that ketamine should be a treatment of last resort for depression after failure. other methods.
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